Birth rates now are about half of what they were during the height of the “baby boom.” That’s because women are waiting to start their family until they are more settled in their careers, relationships and lifestyles. Unfortunately, this same study also found that about 40% of women between 44 and 50 years of age have had fewer children then they would have preferred. That’s why it is so important that women consider what their family buildings are and consider egg freezing during their mid thirties. Technology now offers women the best of both worlds; delayed reproduction and achieving their ideal family size! https://www.washingtonpost.com/news/wonk/wp/2016/08/16/why-american-women-are-having-fewer-babies-than-ever/

You were born with every egg that you’ll ever have. Although studies suggest that there may be a process where we can create eggs; such technology is far into the future. More importantly, you’re losing eggs at a rate that far exceeds what you would guess. Current research suggests that most women will lose about 500 to 1000 eggs per month through a process of attrition called apoptosis—yet only one or two eggs each month will be capable of fertilization. A recent summary of all of the available research has shown that most women will only have about 3% of their eggs remaining by age 40.

Although the slope of that curve appears intimidating, the goal of this blog post is to increase your awareness and to empower you to take action. Some women are born with more eggs than others. Some women will lose their eggs at a faster rate. Most importantly, the eggs that remain in your ovaries at any given moment represent your ovarian reserve. Therefore, it is very relevant for you to consider how many eggs you have now and then plan how many (more) children you think you might someday wish to have.

This diagram shows the various stages of egg development summarized in a single ovary.

It takes an egg several months to develop from its status as a primordial follicle to that of a mature fertilizable oocyte. It is only when they reach that stage that the ovary releases the egg through a process called ovulation. Fewer than 300 of your eggs are likely to ever complete this journey. In other posts on this blog, we focus on various steps you can take to optimize the health of your developing eggs; but for now let’s focus on the future of your fertility in the months and years to come.

At least 99% of your remaining eggs are dormant—alive but not metabolically active. They have been in this resting state since you were a newborn. The eggs that are in these intermediate stages of development—which represents your fertility—can be estimated by a simple well timed blood test. Consider having your ovarian reserve tested today. Then think about how many children you envision yourself having. Consider when you will be ready to start or expand your family. By doing so, you can better estimate whether or not egg freezing or embryo banking (creating and storing embryos for future use) are steps you should be considering to assist you in creating your future family.

One of the most frustrating questions for women trying to conceive is “what can I do to improve my chances?” Given that women are born with every egg that they will ever have, there are a limited number of ways to optimize the health of the remaining eggs. But for those that are motivated, I have described steps like the use of Acai berry extract and CoQ10 as well as improved sleep and Vitamin D. Now for the first time, there is evidence that some women may be able to improve the responsiveness of their ovaries in as little as one month!

The typical diet of people living in the USA has changed dramatically over the last century. One glaring example has been in the type of fats that we consume on a daily basis. Essential dietary fats—those that we must get from foods because our bodies can’t make them—are typically classified as Omega-6 and as Omega-3 and serve many important physiologic functions. The ideal ratio of Omega-6 to Omega-3 is 1-to-1. However, the typical Western diet—popular amongst most Americans—has a ratio as high as 25-to-1. The result of this unhealthy shift is that many people are eating foods that promote inflammation. This unhealthy shift is associated with a higher risk of heart disease, diabetes, cancer and infertility.

Given that it’s not easy to encourage people to make lasting dietary changes, a recent study looked at the effects of starting a high potency omega-3 fatty acid supplement upon ovarian function and hormone balance. For this study, they put 27 women on a 4 gram supplement and measured their FSH levels before and 30 days after starting this program. Even within this short time frame—effectively one menstrual cycle—they found a dramatic improvement in the omega-6 to omega-3 ratio. Their inflammatory markers improved and their FSH levels dropped. Given that FSH level is considered a marker of ovarian sensitivity; this result is interpreted to mean that their ovaries were more sensitive and thus more fertile.

A cautionary note; they did not find an improved ovarian sensitivity in the women in the study that were obese. It is possible that with longer time and with weight loss, obese women might also experience improved fertility. Obesity has been linked to worsening infertility as well as resistance to some of the treatments offered to normal weight women. It is theorized that obesity itself produces inflammatory chemicals in the body which in turn trigger a state of hormone imbalance. In act, it was discovered that all of the women in the study—including the women that were obese—had improved markers of glucose metabolism. That suggests that the omega-3 fatty acids could help reduce the risk of diabetes and maybe make it easier to lose weight as well.

Another important benefit of omega-3 fatty acids is that they can reduce oxidative stress. That means that consuming these healthy dietary fats can reduce the risk of DNA damage to a woman’s eggs—another important fertility promoting benefit. So although this was a small study and needs to be confirmed in a longer time period, you don’t need to wait. Make this health promoting change in your fertility promoting plan now. Here are a few practical suggestions:

One of the greatest challenges in reproductive medicine is trying to figure out ways to improve pregnancy rates for women that produce a limited number of eggs. Other posts on this blog[u1] address various steps to try to optimize/improve egg quality[u2] . But new data suggests that the use of intracytoplasmic sperm injection (ICSI) can improve embryo formation and more importantly increase a woman’s chance of becoming pregnant. Traditionally, ICSI has been used to overcome male factor infertility. Over the last several years, some centers have included it in all of their treatment cycles as a means of maximizing fertilization. Some experts criticized this practice since it was based upon a theory rather than clinical proof of an improved outcome. In fact, the American Society for Reproductive Medicine has a Patient Fact Sheet [u3] that describes the guidelines for the use of ICSI (last revised in 2008). Recently a large study attempted to settle this debate on whether or not ICSI should be used in women considered to be “poor responders” to fertility therapy.

One of the limitations of previous studies on “diminished ovarian reserve (DOR)” was the lack of an agreed upon definition of how to diagnose this condition. In 2011 an international meeting was held to form a consensus [u4] on the identification of “poor response to ovarian stimulation.” Their goal was to improve the design of future studies and provide practical guidelines as well as assist doctors in the diagnosis of this condition. To meet diagnostic criteria it was agreed that a woman must have at least two of the following:

The recent study [u6] referred to in this blog post followed over 1000 IVF patients that had failed on a previous cycle and met the new criteria for “poor responders.” These patient/couples completed nearly 3000 total cycles of IVF with ICSI. They found that including ICSI—despite a normal sperm count—improved the ongoing pregnancy rate by 40%. Another noteworthy fact is that this study was performed in Israel where IVF is a fully covered health benefit for all citizens. This made it possible for patients to continue treatment without concern of cost thereby removing a “selection bias.” The potential benefit of ICSI—in the absence of a male factor—does make sense. Some studies show that women with DOR have a thicker coating on the egg making it more difficult for a healthy sperm to enter. Selecting a sperm for use in ICSI may also reduce the possibility of an abnormal sperm fertilizing an otherwise limited number of healthy eggs. Whatever the reason, most women with a poor response to fertilization are immediately directed to use donor eggs. However, this study found that ~35% of these “poor responders” achieved a successful pregnancy within 5 to 7 IVF attempts. The bottom line is that couples that would otherwise have been discouraged from completing a second attempt went on to have a baby at least 1/3 of the time.

So discuss with your doctor whether or not you may benefit from including ICSI in your next IVF cycle. In doing so, be careful to ask if there is an additional charge for this service. At CNY Fertility[r7] Center, we are pleased to offer this augmented fertilization technique to all of our patients as part of the standard IVF cycle (included in the standard fee). Now we have more data supporting this recommendation.

Our society puts a priority on reproduction. That makes sense since it is hardwired into our brain. Unfortunately, that value often results in the assumption that women that choose to wait and begin their family later in life are somehow selfish or narcissistic for “wanting to have it all.” I am pleased to share that a recent report made great strides in dispelling this myth.

A British psychologist recently performed a thorough review [r1] of women’s motivations and situations resulting in “delayed motherhood.” In fact, she even took exception with the term “delayed” because it so strongly suggests that it is a choice that women are consciously making to wait until their late thirties or early forties to become pregnant. Instead, she found that it more often women are responding to their situation. Her research revealed that many women today are having babies later as a result of strategic decision making, extensive negotiations or response to their life’s circumstances. Better still women today have more options to preserve their fertility.

Techniques [r2] are available today to more efficiently freeze and store unfertilized eggs or viable embryos. Embryo freezing has been available for several decades but the efficiency of the process is much greater today. Egg freezing now makes it possible for women to preserve their unfertilized eggs when they are more plentiful and at their healthiest but actually delay fertilization and pregnancy until the time is right. Recently, the technique for freezing unfertilized eggs has been refined so much and the availability of the procedure [r3] has become so readily available that it is no longer considered experimental. So as more women speak out [r4] about their own choices and empower others to do so, it is rewarding to be able to meet their needs with more treatment options.

One of the most vexing problems in human reproduction has been the accepted fact that women are born with every egg that they are ever going to have. As women age, the number of viable eggs goes down until she is no longer able to conceive her own biological child. A new study [u1] has questioned this current position by actually creating new eggs from stem cells.

Stem cells are the special cells within the body that have not been assigned a specific identity. As a result, they can become kidney cells or skin cells or muscle cells. But until now, there has not been confirmation that they can become the special cells that are necessary to support reproduction (eggs or sperm). This new study has changed that perspective.

It is important to point out that this is the first report and therefore the technique needs to be repeated and verified before we can be certain of this new breakthrough. It is also noteworthy that this study involved a process where women were having their ovaries removed as part of gender re-assignment surgery. The ovaries were then processed in the lab in order to derive the cells that reportedly produced a limited number of eggs. It is therefore possible that even if this study is confirmed that it will only apply to young women and that the technique would require that they lose an ovary in order to create these eggs. Since it is older women that typically need to generate new eggs, we aren’t yet certain that this new breakthrough will ever be of practical value to women most in need of these results. Nonetheless, each step toward overcoming a potential barrier to reproduction is cause for celebration—even if we simply develop new information that assists us in understanding other aspects of reproduction.

It is well known that as a woman ages, her ability to have a child with her own eggs declines and eventually ceases altogether. What has not been well studied nor as widely discussed is the impact that paternal age has upon fertility. With a growing number of couples delaying marriage or remarrying, there are more men in their forties, fifties and sixties that are trying to father a child. In the USA, the birthrate of children to men between 35 and 54 years of age has gone up by over 30% between 1980 and 2000[g1]. There is evidence that this trend is continuing to rise.

Advanced paternal age has been associated with a higher risk miscarriage in at least one study. Other studies suggest that women with an older partner are at higher risk of pregnancy complications. But the data on the chance of actually conceiving is more difficult to interpret.

As men a man becomes older the volume of semen that he produces declines. We know also that the number of sperm producing cells and the production of testosterone decreases as well. We also know that the hormone signal from his brain to the sperm producing cells increases suggesting that they are less sensitive to this signal. But the factors that we typically evaluate to assess male fertility--sperm count, sperm motility and sperm shape (morphology)--do not predictably decline as a man reaches his 50’s or 60’s. So to answer the question of male fertility and aging, we get the most predictable information by looking at the results of IVF treatment.

When pregnancies are created through advanced reproductive techniques like IVF; we are able to directly observe the ability of sperm to fertilize an egg and then track how the embryo develops. Better still, we can then follow the outcome of those embryos in order to determine how well they implant and how often the result in the birth of a healthy baby. Recently, a review [g2]was published that tried to gather and quantify all of the studies published so far that could help answer this question. Here is what they found:

· Fertilization Rate—this is defined by the ability of a sperm to penetrate an egg and initiate embryo development. The existing studies do not show a decline in this critical step associated with aging in men.

· Embryo Development—is the critical stage that an egg must go through before it can implant into a woman's uterus. This is a process that typically takes place over 5-6 days. The first three days are not impacted by sperm quality and therefore are not impacted by the age of the male. Studies do suggest that there is a greater decline in embryo quality between day 3 and day 6 as men age suggesting that sperm quality may be impacted by age.

· Implantation Rate—this is determined by the positive pregnancy rate following embryo transfer. The data suggests that the implantation rate does decline with paternal age but this does not become a noticeable impact upon success until a man is older than 60 years of age.

· Birth Rate—the data on live birth rate is conflicted. Some studies show a lower birth rate after implantation as a man ages while others found no higher risk of miscarriage. Typically, such inconsistent results suggest that it is not strictly an age related phenomenon and may in fact be impacted by other factors.